“th On 25 September 2017 I concluded this inquest by way of a narrative conclusion”

The coroner’s concerns

th On 25 September 2017 I concluded this inquest by way of a narrative conclusion. I indicated at the end of the inquest that it was my intention to write a report due to a concern about future deaths. Mr Cosgrove found himself being discharged back to the nursing home from where he had originally been admitted to hospital at a time when seemingly unknown to the hospital staff - including a senior member of the nursing staff for the ward - he had a dislocated hip. The fact that there was a problem with the hip seems to have become quickly apparent to care home staff upon his return to that home and to a General Practitioner who visited him although once the dislocation was in fact recognised it was treated conservatively given the patient's co-morbidities. The concerns are:    rd Despite an entry in the clinical records made by a doctor on 3 March 2017 which refers to a rotating right leg, neither the issue he identifies nor his entry in the notes appear to have been appreciated by nursing staff who cared for Mr Cosgrove thereafter. A Sister who was a clear and helpful witness acknowledged in court that rd the issue identified by the doctor on 3 March 2017 was not considered as part of his rd plan of care subsequently. This is despite the fact that between 3 March 2017 and discharge from hospital he was seen regularly by staff with responsibility for physically rolling him with a view to providing pressure relief. Although from the evidence it is not known how the dislocation occurred the fact it does not appear to have been recognised over a period of 7 days is concerning and strongly suggests that staff paid insufficient regard to the patient’s previous medical record entries. Patients such as Mr Cosgrove should not find themselves being discharged from hospital in such circumstances and at a time when the medical professionals looking after his welfare are unaware of such an issue. th But for the fact he was discharged from hospital on 10 March 2017 and that this resulted in the dislocation problem being identified, had he spent a lengthier period in hospital the dislocation and developing infection may well have continued to go unrecognised which raises a concern about how effectively patients are being monitored and their medical records are being considered by staff who are subsequently involved in that patient’s care. On this occasion once the dislocation issue was identified this did not substantially alter his care and he was treated conservatively, but in other circumstances not recognising the problem may have directly caused a death. At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2017-0285

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0